Insulin dispensing error (02HDC07385)

Following a four-hourly glucose
testing regimen, commenced to investigate poorly controlled Type 2
diabetes mellitus, an 87-year-old man was prescribed Humulin 70/30
by his GP. Humulin 70/30 is a mixture of isophane insulin
(brand-name Humulin N), 70%, and Humulin R (which is similar to
Actrapid), 30%. As it is a relatively uncommon medication, the GP
talked to the patient's pharmacy about the change to ensure a
smooth transition.

The patient was dispensed the medication correctly until he
changed pharmacy a month later. On the next three visits the
patient was dispensed Humulin N, not Humulin 70/30. The next month
the patient was again dispensed Humulin N, but this time in a box
labelled as Humulin 70/30. The pharmacy's computer system began to
automatically restock Humulin 70/30, but this was the first time it
had been stocked at the pharmacy. The following month the patient
was again dispensed Humulin N in a box marked "Humulin
70/30".

Later that month the patient was admitted to hospital after he
collapsed following recent cataract surgery. During his admission
the pharmacy correctly dispensed his Humulin 70/30, but noticed
that it was a different colour from the Humulin N previously
dispensed. Staff at the pharmacy carried out an audit of their
stocks and discovered that they had been dispensing Humulin N
instead of Humulin 70/30. One of the pharmacists involved later met
with the patient's family, GP and hospital staff to discuss the
errors and apologise.

The three pharmacists who dispensed the insulin were unaware of
the product Humulin 70/30. When confronted with a prescription for
"Humulin 70/30 Inj with Neutral Insulin", they assumed that the
"Neutral" referred to Humulin N, with which they were familiar. All
three pharmacists were found in breach of Right 4(2) of the Code in
not following the Standard Operating Procedures for the pharmacy or
the Pharmaceutical Society's Code of Ethics. They failed to
scrutinise all the relevant information, in particular the figure
"70/30", and should not have assumed that the prescription was for
Humulin N.